Lack of coverage for first-line treatments of pigmentary disorders in contrast to treatments of acne and rosacea: A survey of public and private insurers in California
Authors: Mekaleya Tilahun, Jenna C. Lester
Journal: Journal of the American Academy of Dermatology (2023)

Pigmentary disorders are commonly diagnosed in patients with dark skin and are often classified as cosmetic by insurance companies, resulting in treatment coverage denial.1Halder R.M. Nootheti P.K. Ethnic skin disorders overview.J Am Acad Dermatol. 2003; 48: S143-S148https://doi.org/10.1067/mjd.2003.274Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar,2Sun H. Lim J.S. Silva C.F. Maczuga S.A. Hollins L.C. Insurance coverage gap for treatment of melasma compared with rosacea: it pays to be light.Br J Dermatol. 2021; 185: 1252-1254https://doi.org/10.1111/bjd.20641Crossref PubMed Scopus (2) Google Scholar In one study, patients with rosacea were 26 times more likely to obtain prescription treatment compared with patients with melasma despite them sharing several clinical features.2Sun H. Lim J.S. Silva C.F. Maczuga S.A. Hollins L.C. Insurance coverage gap for treatment of melasma compared with rosacea: it pays to be light.Br J Dermatol. 2021; 185: 1252-1254https://doi.org/10.1111/bjd.20641Crossref PubMed Scopus (2) Google Scholar Given that melasma disproportionately affects patients of color, this suggests that these patients are less likely to access appropriate health care.2Sun H. Lim J.S. Silva C.F. Maczuga S.A. Hollins L.C. Insurance coverage gap for treatment of melasma compared with rosacea: it pays to be light.Br J Dermatol. 2021; 185: 1252-1254https://doi.org/10.1111/bjd.20641Crossref PubMed Scopus (2) Google Scholar We compared insurance coverage for first-line treatments of melasma, postinflammatory hyperpigmentation (PIH), and vitiligo to rosacea and acne. We performed a literature review to identify expert agreement on first-line treatments of melasma, PIH, vitiligo, rosacea, and acne, and reviewed online formularies of insurance companies with the most enrollments in California to determine coverage status. If needed, we spoke to insurance representatives over the phone.32021 Edition—California Health Insurance EnrollmentCalifornia Health Care Foundation.https://www.chcf.org/publication/2021-edition-california-health-insurance-enrollment/Date accessed: June 30, 2022Google Scholar First-line treatments for melasma and PIH were not covered by any insurance company; vitiligo treatment coverage varied. Most treatments for rosacea and acne were covered (Table I). Like rosacea and most forms of acne, melasma, vitiligo, and PIH manifest cutaneously, and their first-line treatments are aimed at addressing skin-limited disease. Despite these similarities, treatments for these conditions have different coverage patterns. None of the insurance companies surveyed covered treatments for melasma or PIH—conditions commonly diagnosed in patients with skin of color.1Halder R.M. Nootheti P.K. Ethnic skin disorders overview.J Am Acad Dermatol. 2003; 48: S143-S148https://doi.org/10.1067/mjd.2003.274Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar Lack of coverage may lead to increased out-of-pocket costs for patients with these conditions, thereby creating a considerable financial burden. In comparison to acne and rosacea, few treatments exist for melasma and PIH. This may be due to a lack of prioritization of and investment in research on these conditions, representing a structural inequity that may disproportionately affect people of color. The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) of 2020 widens this inaccessibility by banning all over-the-counter products containing hydroquinone.Table IInsurance companies with the most enrollments in California: Coverage patterns for treatments of melasma, postinflammatory hyperpigmentation, rosacea, vitiligo, and acneMedicaidMedicareBlue ShieldUnitedKaiserAnthemMelasmaHydroquinoneHydroquinoneHydroquinoneHydroquinoneHydroquinoneHydroquinoneTCCTCCTCCTCCTCCTCCPIHHydroquinoneHydroquinoneHydroquinoneHydroquinoneHydroquinoneHydroquinoneRosaceaTopical brimonidineTopical brimonidineTopical brimonidine†Coverage with restrictions: quantity limits.Topical brimonidine†Coverage with restrictions: quantity limits.Topical brimonidineTopical brimonidineTopical oxymetazolineTopical oxymetazolineTopical oxymetazoline∗Coverage with restrictions: prior authorization.†Coverage with restrictions: quantity limits.Topical oxymetazoline∗Coverage with restrictions: prior authorization.†Coverage with restrictions: quantity limits.Topical oxymetazolineTopical oxymetazolineAzelaic acidAzelaic acidAzelaic acid†Coverage with restrictions: quantity limits.Azelaic acidAzelaic acidAzelaic acid†Coverage with restrictions: quantity limits.Topical ivermectin∗Coverage with restrictions: prior authorization.†Coverage with restrictions: quantity limits.Topical ivermectinTopical ivermectin∗Coverage with restrictions: prior authorization.†Coverage with restrictions: quantity limits.Topical ivermectinTopical ivermectinTopical ivermectinTopical metronidazoleTopical metronidazoleTopical metronidazoleTopical metronidazoleTopical metronidazoleTopical metronidazoleOral tetracyclinesOral tetracyclinesOral tetracyclinesOral tetracyclinesOral tetracyclinesOral tetracyclines†Coverage with restrictions: quantity limits.Oral isotretinoinOral isotretinoin†Coverage with restrictions: quantity limits.Oral isotretinoinOral isotretinoinOral isotretinoin†Coverage with restrictions: quantity limits.Isotretinoin∗Coverage with restrictions: prior authorization.VitiligoTopical steroidsTopical steroids∗Coverage with restrictions: prior authorization.Topical steroidsTopical steroidsTopical steroidsTopical steroidsTopical calcineurin inhibitors‡Coverage with restrictions: age limits.Topical calcineurin inhibitors∗Coverage with restrictions: prior authorization.Topical calcineurin inhibitors†Coverage with restrictions: quantity limits.‡Coverage with restrictions: age limits.‖Coverage with restrictions: step therapy.Topical calcineurin inhibitors∗Coverage with restrictions: prior authorization.‖Coverage with restrictions: step therapy.Topical calcineurin inhibitorsTopical calcineurin inhibitors∗Coverage with restrictions: prior authorization.†Coverage with restrictions: quantity limits.UV-B§No coverage.UV-BUV-B§No coverage.UV-BUV-B§No coverage.UV-BAcneTopical retinoids∗Coverage with restrictions: prior authorization.Topical retinoids∗Coverage with restrictions: prior authorization.Topical retinoids∗Coverage with restrictions: prior authorization.‡Coverage with restrictions: age limits.Topical retinoids†Coverage with restrictions: quantity limits.Topical retinoidsTopical retinoids∗Coverage with restrictions: prior authorization.†Coverage with restrictions: quantity limits.Systemic antibioticsSystemic antibioticsSystemic antibioticsSystemic antibioticsSystemic antibioticsSystemic antibiotics†Coverage with restrictions: quantity limits.SpironolactoneSpironolactoneSpironolactoneSpironolactoneSpironolactoneSpironolactoneIsotretinoinIsotretinoin†Coverage with restrictions: quantity limits.IsotretinoinIsotretinoinIsotretinoin†Coverage with restrictions: quantity limits.Isotretinoin∗Coverage with restrictions: prior authorization.Boldfaced text indicates full coverage, italicized text indicates coverage with restrictions, underlined text indicates unclear coverage that may be dependent on medical necessity, and boldface and italicized text indicates no coverage.PIH, Postinflammatory hyperpigmentation; TCC, triple combination cream.∗ Coverage with restrictions: prior authorization.† Coverage with restrictions: quantity limits.‡ Coverage with restrictions: age limits.§ No coverage.‖ Coverage with restrictions: step therapy. Open table in a new tab Boldfaced text indicates full coverage, italicized text indicates coverage with restrictions, underlined text indicates unclear coverage that may be dependent on medical necessity, and boldface and italicized text indicates no coverage. PIH, Postinflammatory hyperpigmentation; TCC, triple combination cream. Due to their chronicity and visibility, pigmentary disorders cause a considerable psychological impact on patients.1Halder R.M. Nootheti P.K. Ethnic skin disorders overview.J Am Acad Dermatol. 2003; 48: S143-S148https://doi.org/10.1067/mjd.2003.274Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar In one study, almost half of the non-White adult women with PIH was severely troubled by their condition, which often caused more distress than the inciting acne.4Alexis A.F. Harper J.C. Stein Gold L.F. Tan J.K.L. Treating acne in patients with skin of color.Semin Cutan Med Surg. 2018; 37: S71-S73https://doi.org/10.12788/j.sder.2018.027Crossref PubMed Google Scholar Patients with melasma report feelings of frustration, embarrassment, and depression due to their condition.5Kagha K. Fabi S. Goldman M.P. Melasma's impact on quality of life.J Drugs Dermatol JDD. 2020; 19: 184-187https://doi.org/10.36849/JDD.2020.4663Crossref PubMed Scopus (8) Google Scholar Lack of treatment coverage may result in worsened or unresolved clinical symptoms, which contributes to the psychological burden felt by patients with these conditions. We captured California's diverse population by evaluating both public and private insurance coverage. Our findings are limited to first-line treatment coverage by the most popular insurance coverage plans in California, excluding Medicare Part D plans, and thus, may not be generalizable to other states. Furthermore, coverage information is subject to change. Melasma and PIH treatments are excluded from coverage by the top 5 most popular insurance companies in California due to their cosmetic classification. These conditions often present in people of color; and thus, treatment inaccessibility may disproportionately impact this group, increasing their out-of-pocket costs and psychological distress. Dermatologists are needed to bring awareness to this issue and advocate for meaningful policy changes to improve insurance coverage. None disclosed.